Picking up the most recent issue of The American Journal of Psychoanalysis, Marshal skimmed the table of contents but closed it quickly. Seventeen hundred dollars! Christ, why hadn't he bought more? Leaning back in his leather swivel chair, he surveyed the view in his office: the Hundertwasser and the Chagall prints, the collection of eighteenth-century wineglasses with delicately twisted, ribboned stems brilliantly displayed in a highly polished rosewood cabinet. Most of all he enjoyed his three glorious pieces of glass sculpture by Musler. He rose to dust them with an old feather duster his father had once used to dust the shelves in his tiny grocery store on Fifth and R streets in Washington.
Though he rotated the paintings and prints of his large collection at home, the delicate sherry glasses and the fragile Musler pieces were permanent office fixtures. After checking the earthquake-proof mountings of the glass sculptures, he lovingly caressed his favorite one: The Golden Rim of Time, a huge, glowing, wafer-thin orange bowl with edges resembling some futuristic metropolitan skyline. Since acquiring it twelve years ago, he had hardly passed a day without caressing it; its perfect contours and its extraordinary coolness were wonderfully soothing. More than once he had been tempted, only tempted of course, to encourage a distraught patient to stroke it and soak up its cool, calming mystery.
Thank God he had overridden his wife's wishes and bought the three pieces: they had been his best purchases. And possibly his last. Musler's prices had escalated so much that another piece would cost
76 ^ Lying on the Couch
him six months' salary. But if he could catch another market surge with Standard and Poor futures, as he had last year, perhaps then— but of course his best tipster had been inconsiderate enough to finish therapy. Or perhaps when his two children finished college and graduate school, but that was at least five years away.
Three minutes after eleven, Ernest Lash was late, as usual. Marshal had supervised Ernest for the past two years, and even though Ernest paid ten percent less than a patient, Marshal almost always looked forward to his weekly hour. Ernest was a refreshing break in the day from his clinical caseload—a perfect student: a seeker, bright, receptive to new ideas. A student possessing a vast curiosity—and an even vaster ignorance about psychotherapy.
Though Ernest was old, at thirty-eight, to be still in supervision. Marshal considered that a strength, not a weakness. During Ernest's psychiatric residency, completed over ten years ago, he had staunchly resisted learning anything about psychotherapy. Instead, heeding the siren call of biological psychiatry, he had focused on pharmacological treatment of mental illness, and after residency had elected to spend several years in molecular biological laboratory research.
Ernest was not alone in this. Most of his peers had taken the same stance. Ten years ago psychiatry appeared to be poised on the brink of major biological breakthroughs in biochemical causes of mental disease, in psychopharmacology, in new imaging methods of studying brain anatomy and function, in psychogenetics and the imminent discovery of the chromosomal location of the specific gene for each of the major mental disorders.
But Marshal had not been swayed by these new developments. At sixty-three, he had been a psychiatrist long enough to have lived through several such positivistic swings. He remembered wave after wave of ecstatic optimism (and subsequent disappointment) surrounding the introduction of Thorazine, psychosurgery, Miltown, Reserpine, Pacatal, LSD, Tofranil, lithium. Ecstasy, beta-blockers, Zanax, and Prozac—and was not surprised when some of the molecular biological fervor began to wane, when many extravagant research claims were not substantiated and when scientists began to acknowledge that perhaps, after all, they had not yet located the corrupt chromosome behind every corrupt thought. Last week Marshal had attended a university-sponsored seminar in which leading scientists presented the cutting edge of their work to the Dalai Lama.
Though no advocate of nonmateriahstic world views, he was tickled by the Dalai Lama's response to the scientists' new photos of individual atoms and their certainty that nothing existed outside of matter. "And what about time?" the Dalai Lama had sweetly asked. "Have those molecules been seen yet? And, please, show me the photos of the self, the enduring sense of self?"
After working for years as a researcher in psychogenetics, Ernest grew disenchanted both with research and with academic politics and had entered private practice. For two years, he practiced as a pure psychopharmacologist, seeing patients for twenty-minute appointments and dispensing medications to all. Gradually, and here Seymour Trotter played a role, Ernest realized the limitations, even the vulgarity, of treating all patients with drugs and, at the sacrifice of forty percent of his income, gradually shifted into a psychotherapy practice.
So it was to Ernest's credit. Marshal felt, that he now sought out expert psychotherapy supervision and planned to apply for candidacy to the psychoanalytic institute. Marshal shuddered when he thought of all the psychiatrists out there—and all the psychologists, social workers, and counselors as well—who practiced therapy without proper analytic training.
Ernest, as always, rushed into the office, precisely five minutes late, poured himself a cup of coffee, fell into Marshal's white Italian leather chair and riffled through his briefcase for his clinical notes.
Marshal had stopped inquiring into Ernest's lateness. For months, without satisfaction, he had questioned it. Once Marshal had even gone outside and timed the one-block walk between his office and Ernest's. Four minutes! Since Ernest's 11:00 appointment ended at 11:50, there was easily time enough, even with a toilet stop, for Ernest to arrive at noon. Yet some obstacle invariably arose, Ernest claimed: a patient ran overtime, or a phone call demanded attention, or Ernest forgot his notes and had to run back to his office. There was always something.
And that something was obviously resistance. To pay a great deal of money for fifty minutes and then systematically squander ten percent of that money and time, thought Marshal, obviously is patent evidence of ambivalence.
Ordinarily Marshal would have been rocklike in his insistence that the lateness be fully explored. But Ernest wasn't a patient. Not exactly. Supervision lay in the no-man's land between therapy and
7 8 ' ^ Lying on the Couch
education. There were times the good supervisor had to probe beyond the case material and go deeply into the student's unconscious motivations and conflicts. But, without a specific therapy contract, there were limits beyond which the supervisor could not go.
So Marshal let the matter drop, though he made a statement by invariably ending their fifty-minute supervision hour precisely on time—almost to the second.
"A lot to talk about," Ernest began. "I'm not sure where to begin. I want to discuss something different today. No new developments with the two regulars we're following—just had workaday sessions with Jonathan and Wendy; they're doing okay.
"I want to describe a session with Justin in which a lot of coun-tertransference material came up. And also about a social encounter with a former patient I had last night at a bookstore reading."
"Book still selling well?"
"The bookstores are still displaying it. All my friends are reading it. And I've had a few good reviews—one came out this week in the AMA newsletter."
"Great! It's an important book. I'm going to send a copy to my older sister, who lost her husband last summer."
Ernest thought of saying that he'd be glad to autograph that book with a little personal note. But the words froze in his throat. It seemed presumptuous to say that to Marshal.
"Okay, let's get to work . . . Justin . . . Justin. ... " Marshal flipped through his notes. "Justin? Refresh my memory. Wasn't he your long-term obsessive-compulsive? The one with so many marital problems?"
"Yeah. Haven't talked about him for a long time. But you remember we followed his treatment closely for several months."
"I didn't know you were still seeing him. I've forgotten—what was the reason we stopped following him in supervision?"
"
Well, to be honest, the real reason is that I lost interest in him. It became clear he couldn't go much farther. We haven't really been doing therapy . . . more of a holding action. Yet he's still coming in three times a week."
"A holding action—three visits a week? That's a lot of holding." Marshal sat back in his chair and stared at the ceiling, as he usually did when listening hard.
"Well, I worry about that. That's not why I chose to talk about him today, but maybe it's just as well that we address that, too. I
Lying on the Couch ^ 7 9
can't seem to cut him down—and that's three times a week plus a phone call or two!"
"Ernest, do you have a waiting list?"
"A short one. Actually, just one patient. Why?" But Ernest knew exactly where Marshal was heading, and admired his way of asking hard questions with perfect aplomb. Damn, he was tough!
"Well, my point is that many therapists get so threatened by open hours that they unconsciously keep their patients dependent."
"I'm on top of that—and I repeatedly talk to Justin about cutting down our hours. If I were keeping a patient in therapy for the sake of my pocketbook, I wouldn't be sleeping very well at night."
Marshal nodded his head slightly, signaling he was satisfied, for the time being, with Ernest's response. "A couple of minutes ago you said you didn't think he could go farther. Past tense. And now something has happened to change your mind about that?"
Marshal was listening all right—total retention. Ernest looked admiringly at him: rusty-blond hair, alert dark eyes, unblemished skin, the body of a man twenty years younger. Marshal's physique was like his persona: no fat, no waste, solid muscle. He had once played defensive linebacker for the University of Rochester. His thick muscular biceps and freckled forearms completely filled his jacket sleeves—a rock! And a rock, too, in his professional role: no waste, no doubt, always confident, always certain of the right way. Some of the other training analysts also had an air of certainty—a certainty begat by orthodoxy and belief—but none was like Marshal, none spoke with such an informed, flexible authority. Marshal's certainty sprang from some other source, some instinctive sureness of body and mind that dispelled all doubt, that invariably provided him with an immediate and penetrating awareness of the larger issues. Ever since their first meeting ten years ago when Ernest heard Marshal's lecture on analytic psychotherapy, he had used Marshal as a model.
"You're right. To fill you in, I'll need to backtrack a bit," Ernest said. "You may remember that from the beginning Justin explicitly asked my help in leaving his wife. You felt I got overinvolved, that Justin's divorce became my mission, that I became a vigilante. That was when you referred to me as 'therapeutically incontinent,' remember?"
Marshal remembered, of course. He nodded with a smile.
"Well, you were right. My efforts were misdirected. Everything I
8o / Lying on the Couch
did to help Justin leave his wife came to naught. Whenever he came close to leaving, whenever his wife suggested that perhaps they should consider separation, he went into a panic. I came close to hospitalizing him more than once."
"And his wife?" Marshal took out a blank sheet of paper and started taking notes. "Sorry, Ernest, I don't have my old notes."
"What about his wife?" Ernest asked.
"You ever meet with them as a couple? What was she like? She also in therapy?"
"Never met her! Don't even know what she looks like, but I think of her as a demon. She wouldn't come in to see me, said that it was Justin's pathology, not hers. Nor would she get into individual therapy—same reason, I guess. No, there was something else ... I remember Justin telling me she hated shrinks—had seen two or maybe even three of them when she was younger, and each one ended up screwing her or trying to screw her. As you know, I've seen several abused patients, and no one feels more outrage than I at this unconscionable betrayal. Still, if it happened to the same woman twice or three times ... I don't know—maybe we ought to wonder about her unconscious motivations."
"Ernest," Marshal said, shaking his head forcefully, "this is the only time you'll ever hear me say this, but in this one instance, unconscious motivations are irrelevant! When patient-therapist sex occurs, we should forget about dynamics and only look at behavior. Therapists who sexually act out with their patients are invariably irresponsible and destructive. There's no defending them—they should be out of the field! Maybe some patients have sexual conflicts, maybe they want to seduce men—or women—in authority positions, maybe they are sexually compulsive, but that's why they're in therapy. And if the therapist can't understand that and deal with it, then he ought to change professions.
"I've told you," Marshal continued, "I'm on the state medical ethics board. Well, I spent last night reading the cases for next week's monthly meeting in Sacramento. Incidentally, I was going to talk to you about that. I want to nominate you to serve a term on the board. My three-year term is up next month, and I think you'd do an outstanding job. I remember the stand you took in that Seymour Trotter case several years ago. That showed courage and integrity; everyone else was so cowed by the old disgusting bastard that they wouldn't testify against him. You did the profession a
Lying on the Couch ^ ^ i
great service. But what I was going to say," Marshal continued, "was that therapist-patient sexual abuse is getting epidemic. There's a new scandal reported almost every day in the papers. A friend mailed me a story in the Boston Globe that reports on sixteen psychiatrists who have been charged with sexual abuse in the last few years, including some well-known figures: the former chairman at Tufts and one of the senior training analysts of the Boston Institute. And then, of course, there is the case of Jules Masser-man—who, like Trotter, was a past president of the American Psychiatric Association. Can you believe what he did—giving patients sodium pentothal and then having sex with them while they were unconscious? It's unthinkable!"
"Yes, that was the one that shook me up the most," said Ernest. My internship roommates often kid me about spending that year soaking my feet—I had terrible ingrown toenails—and reading Masserman: his Principles of Dynamic Psychiatry was the best textbook I ever read!"
"I know, I know," said Marshal, "all the fallen idols. And it's getting worse! I don't understand what's happening. Last night I read the charges against eight therapists—shocking, disgusting stuff. Can you believe a therapist who slept with—and charged!—his patient for every session, twice a week, for eight years! Or a child psychiatrist, caught in a motel with a fifteen-year-old patient? He was covered with chocolate syrup, and his patient was licking it off! Disgusting! And there was a voyeuristic offense—a therapist treating multiple personality states who hypnotized his patients and encouraged more primitive personalities to emerge and to masturbate in front of him. The therapist's defense was that he never touched his patients—and also that it was proper treatment, first to give these personalities free expression in a safe environment and then gradually to encourage reality testing and integration."
"And all the while getting off sexually while watching them masturbate," Ernest added, sneaking a look at his watch.
"You looked at your watch, Ernest. Can you put that into words?"
"Well, time is going by. I had wanted to get into some material about Justin."
"In other words, though this discussion may be interesting, it's not what you came for. In fact, you'd rather not squander your supervision time and money on it?"
8 2. ^ Lying on the Couch
Ernest shrugged his shoulders.
"Am I close?"
Ernest nodded.
"Then why not say so? It's your time; you're paying for it!"
"Right, Marshal, it's that old business of wanting to please. Of still holding you too much in awe."
"A little less awe and a little more directness will serve this supervision better."
Like a rock, Ernest thought. A mountain. These little exchanges, generally quite separate from the for
mal task of discussing patients, were often the most valuable teaching that Marshal did. Ernest hoped that sooner or later he would internalize Marshal's mental toughness. He also took note of Marshal's draconian attitudes about patient-therapist sexual relations; he had intended to talk about his dilemma involving Nan Carlin at his bookstore reading. Now he wasn't so sure.
Ernest returned to Justin. "Well, the more I worked with Justin, the more I was convinced that any progress made in our hours was immediately undone at home in his relationship with his wife, Carol—an absolute gorgon."
"It's coming back to me. Wasn't she the borderline who threw herself out of the car to stop him from buying bagels and lox?"
Ernest nodded. "That's Carol, all right! The meanest, toughest lady I ever encountered, even indirectly, and I hope never to meet her face to face. As for Justin, for about two to three years I did good traditional work with him: good therapeutic aUiance, clear interpretations of his dynamics, the right professional detachment. Yet I could not budge this guy. I tried everything, raised all the right questions: Why had he chosen to marry Carol? What payoff did he get for staying in the relationship? Why had he chosen to have kids? But nothing we talked about ever got translated into behavior.
"It became apparent to me that our usual assumptions—that enough interpretation and insight will ultimately lead to external change—weren't the answer. I interpreted for years but Justin had, it seemed to me, a total paralysis of the will. You may remember that, as a result of my work with Justin, I became fascinated with the concept of will and began reading everything I could about it: William James, RoUo May, Hannah Arendt, Alan Wheelis, Leslie Farber, Silvano Arieti. I guess it was about two years ago that I gave a grand rounds presentation on paralysis of the will."